CurrentUnitedHealthcarePolicy CSIND0035.09

Immune Globulin (IVIG and SCIG) (for Indiana Only)

Defines UnitedHealthcare Community Plan medical benefit coverage and utilization guidance for FDA-approved intravenous and subcutaneous immune globulin products for members in Indiana.

Policy Summary

PayerUnitedHealthcare

PolicyImmune Globulin (IVIG and SCIG) (for Indiana Only)

Policy CodePolicy CSIND0035.09

Change TypeCode list updateadded J1553

Effective DateApr 1, 2026

Next Review Date

Key ActionObtain prior authorization using current InterQual criteria and applicable plan rules for listed immune globulin products.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable HCPCS codes to reflect quarterly edits and added J1553.

INState

InterQualMedical necessity source

≥20Listed products (examples)

multipleHCPCS/J-codes

Medical Necessity & Coverage Rules

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Primary requirement: Current InterQual guideline criteria must be met for the requested immune globulin (IVIG or SCIG) product and indication

Providers should reference the InterQual criteria linked in the policy; when a product is not listed, package insert prescribing and dosing information will be used to determine benefit coverage.

The list of procedure codes in this policy is provided for reference only. Listing of a code does not imply that the service is a covered health service, nor does inclusion guarantee reimbursement or claim payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws; other policies and guidelines may apply and can affect coverage or payment for services described by the codes in this policy.

This policy does not itself designate services as not medically necessary. Coverage determinations are made by applying the current InterQual clinical criteria together with applicable benefit plan documents and legal requirements. Providers should follow InterQual-based requirements and the member’s contract or plan terms when seeking prior authorization or when evaluating coverage for a given indication.

Applicable Codes & Billing Units

Applicable HCPCS/J-codes (examples)HCPCS

90283	Immune globulin (IgIV), human, for intravenous use.
90284	Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each.
J1459	Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg.
J1551	Injection, immune globulin (Cutaquig), 100 mg.
J1552	Injection, immune globulin (Alyglo), 500 mg.
J1553	Injection, immune globulin (yimmugo), 100 mg.
J1554	Injection, immune globulin (Asceniv), 500 mg.
J1555	Injection, immune globulin (Cuvitru), 100mg.
J1556	Injection, immune globulin (Bivigam), 500 mg.
J1557	Injection, immune globulin, (Gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg.

1–10 of 19

1/2

Not otherwise specified codesHCPCS

J1599

Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg.

HCPCS unit basis

Unit descriptorsMost J‑codes are defined per either 100 mg or 500 mg units (e.g., J1551, J1553, J1555, J1558, J1559, J1575 = 100 mg; J1459, J1552, J1554, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1576, J1599 = 500 mg).

90284 / SCIG billing basis90284 is specified as 'Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each' (100 mg unit basis).

Nonlyophilized IVIG codesSeveral intravenous liquid (nonlyophilized) products are listed with a 500 mg unit basis (examples: J1459 Privigen, J1557 Gammaplex, J1561 Gamunex‑C/Gammaked).

Lyophilized (powder) codeJ1566 is described as 'Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg' (500 mg unit).

Not otherwise specified (NOS) code unitJ1599 (NOS) is listed as 500 mg: 'Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg.'

Prior Auth, Documentation, & Routing

Prior Authorization

Prior Authorization Required — InterQual Criteria

Prior authorization is required and reviews are conducted using InterQual clinical criteria. Providers must reference the applicable benefit documents for the member (federal, state, or contractual requirements) as benefit coverage may differ from the standard plan and governs in the event of a conflict.

Prior authorization must reference InterQual specialty pathways specific to the product requested.
Benefit plan terms (federal, state, contractual) supersede this policy when conflicts exist; verify member-specific coverage before submission.
Include relevant clinical documentation consistent with InterQual requirements to support medical necessity.

Documentation Required

Product → InterQual Pathway Mapping

Product-level pathway mappings to InterQual specialty pathways are used to determine medical necessity. When requesting authorization, map the specific IG product to its corresponding InterQual pathway to ensure correct clinical review.

Alyglo — InterQual: CP: Specialty Rx Non-Oncology, Immune globulin, intravenous (IVIG) (Alyglo)
Cutaquig — InterQual: CP: Specialty Rx Non-Oncology, Immune globulin, subcutaneous (SCIG) (Cutaquig)
Privigen — InterQual: CP: Specialty Rx Non-Oncology, Immune globulin, intravenous (IVIG) (Privigen)
Xembify, Hizentra, Gamunex-C, Gammaked, Gammaplex, Gammagard (liquid/S/D), Octagam, Panzyga, Bivigam, Asceniv, Cuvitru, Yimmugo — map to their respective InterQual IVIG or SCIG specialty pathways as listed in InterQual product mappings.

Note

Coverage Depends on Benefit Plan

Coverage is dependent on the member's benefit plan. Listing of a code or product in this section does not imply coverage or payment. Always verify the members benefit plan and applicable legal requirements before billing or administering therapy.

Listing of codes or products in this policy is for reference only and does not guarantee reimbursement.
Prior authorization approval does not ensure payment; claims are subject to member eligibility, benefit limits, and other applicable policies.

Clinical Background

Intravenous (IVIG) and subcutaneous (SCIG) immune globulin products are used to treat a range of immune deficiency and autoimmune conditions. This medical benefit drug policy covers FDA‑approved IVIG and SCIG products when the current InterQual medical necessity criteria for the requested product and indication are met, and it references product-specific HCPCS/J‑codes for billing. When a product or indication is not specifically listed, providers should reference InterQual and the product package insert for dosing and clinical eligibility guidance.

Key Definitions & Guideline Sources

InterQual guideline (primary medical necessity source)

Primary medical necessity sourceInterQual clinical guideline is the current primary source for medical necessity criteria for immune globulin coverage; providers must follow InterQual criteria for the requested product and indication.

Product mapping to InterQual pathwaysEach listed product is mapped to a Clinical Program (CP) pathway (e.g., Specialty Rx Non‑Oncology Immune globulin IVIG or SCIG) for review per InterQual.

When product not listedIf a product is not listed in the policy, package insert prescribing and dosing information is used in addition to InterQual criteria to determine coverage.

Access to InterQual criteriaThe policy provides a link: 'Click here to view the InterQual ® criteria' for detailed pathway and criteria references.

Routing & Initial Authorization

Initial authorization routing — product-level routing to InterQual specialty pathways

Product-level routing for initial prior authorization — requests are routed to the mapped InterQual specialty pathway for clinical review

Product mapping: Each listed immune globulin product is routed to the corresponding Clinical Program (CP): Specialty Rx Non-Oncology Immune globulin pathway (IVIG or SCIG) for InterQual review

See product list in policy for exact CP mappings (examples include Alyglo, Asceniv, Bivigam, Cutaquig, Cuvitru, Privigen, Octagam, Panzyga, Xembify, Yimmugo, etc.).

Step Therapy & Edit Notes

Step	Description
0
No explicit step edits are defined. Authorization is routed via product-specific Clinical Program (CP) mappings to InterQual specialty pathways (e.g., CP: Specialty Rx Non‑Oncology, Immune globulin, IVIG or SCIG for listed products), implying clinical pathway–based review rather than a prescriptive step sequence.

Administration Setting Guidance